Debate: 'Is obesity a disease'

I haven't had time to watch this yet, but I'm just putting it out there for discussion. It should be interesting.

Dr. Jacqui Gingras is a HAES advocate and Dr. Arya Sharma is Alberta's leading expert on obesity. I think it's fair to say that Dr. Sharma is somewhat less enmeshed in the size=health paradigm and in social prejudice than many others in his field. I'm hoping that it's going to be a sane and reasonable discussion.

Dr Arya Sharma and Dr Jacqui Gingras debate whether obesity should be viewed as a disease in Ottawa, Ontario on June 7, 2012. The event was moderated by Dr Mark Tremblay, and was supported by a Café Scientifique grant from the Canadian Institutes of Health Research as well as an event grant from the Canadian Obesity Network and in-kind support from the Healthy Active Living and Obesity Research Group at the Children's Hospital of Eastern Ontario Research Institute. To download the audio of the debate, visit http://blogs.plos.org/obesitypanacea/2012/06/13/is-obesity-a-disease-debate-r.... Video by Joseph Abdulnour.

1. If only all those on the other side were as open-minded as Dr. Sharma! Simply changing the medical definition of obesity from "BMI > 30" to "Has significant health problems caused by weight" would be a big step in the right direction. I just had my first general doctor's appointment in about five years, and of course the doctor brought up weight right away. But when my blood work came back, it was perfectly fine except for a vitamin D deficiency common to NYC officeworkers. The only thing wrong was high blood pressure. I expect Dr. Sharma, based on what he says in this debate, wouldn't have brought up weight at all, and certainly would have shut down immediately after I said I wasn't interested in weight loss.

2. Dr. Gingras is right, but brings up healthism way too late in the argument and really doesn't hit the biggest problem, which is how obesity as a medical issue allows stigmatization of fat people as a national budget scapegoat. I don't like the cultural assumption that fat people are lazy, private discrimination, etc., but at least I can always ignore private jerks. I can't ignore government mandates and political movements.

3. One common point Dr. Sharma kept bringing up is bizarre--" We need to treat obesity as a medical condition so that obesity treatments will come from doctors, not internet quacks." This would be more plausible if the medical establishment had any credibility. I think Dr. Gingras, being a doctor, was unwilling to point out the terrible track record of doctors on obesity and weight loss.

The problem is that medicalizing obesity in practice is still pathologizing fat. I think there are 4 ways a doctor can think about it:

1. Fat is a moral/social/character issue that causes hypertension/infertility/diabetes. This is the worst version, because these doctors will withhold all treatment for real medical conditions.

2. Obesity is a medical condition that causes hypertension/infertility/diabtetes. This is still very bad, because while at least the doctor won't send you away without any treatment, he'll still focus on weight instead of the real medical problem.

3. Obesity is a medical condition that is associated with but independent from hypertension/infertility/diabtetes. This is fine, because while the doctor will lecture us about weight, we can ignore it and the doctor will still treat the real medical problem. These doctors are annoying but harmless.

4. Obesity is not a medical condition, but hypertension/infertility/diabtetes is. This is ideal, because it recognizes that weight, in itself, is not the problem. These doctors are essentially following HAES.

Dr. Sharma is following version 3, as does my doctor, which is fine. But the political push in the US and Britain seems to be towards versions 1 and 2, because they can cut costs and scapegoat fat people. And I don't think the debate really discusses the difference between versions 2 and 3.

Debra, I agree with you completely that when I've read Dr. Sharma, he has pushed back against the notion that fat people overeat and are physically inactive--at least compared to thin people. I don't follow his blog closely, but here's a link I saved from a while back that is about as clear and explicit about that as you could ask for, to supplement your more recent link.

However, I don't think that he should call what he's advocating HAES--I'm not sure from your comment if you think he should or not, but HAES advocates recognize that weight gain is among the possible outcomes of practicing HAES. (Although weight usually stabilizes after doing HAES for a while, if the person is starting from below their set point the assumption is that they will gain weight). My understanding is that Dr. Sharma recommends maintenance for anyone who is above a BMI of 25 and experiencing no health problems, so even for people experiencing no weight-related health problems he is not quite advocating health at every size, and certainly that's not what he's advocating for people who do have weight-related health problems.

3. Obesity is a medical condition that is associated with but independent from hypertension/infertility/diabtetes. This is fine, because while the doctor will lecture us about weight, we can ignore it and the doctor will still treat the real medical problem. These doctors are annoying but harmless.

Not sure I'd go so far as to call them harmless, as being badgered about weight is still one of the main reasons fat people avoid doctors; knowing that it's an inevitability is not going to encourage those who feel uncomfortable being lectured about their 'obesity' to visit, which in turn can result in substandard (or nonexistent) care and diagnosis of potentially serious conditions being delayed, particularly as in reality there's a lot of overlap of attitudes between types 2 and 3.

However on your point about being able to ignore individual jerks I agree wholeheartedly. What's more, enough individual jerks, mobilised by a media that caters to whichever opinion will garner the highest ratings or number of pageviews, and sufficiently vocal to attract attention, can create the demand or even the illusion of demand (which are much the same thing, in effect) for political policies, action and all the rest, which are much more difficult to ignore than some idiot hollering an insult from a moving car.

And as I've said in the past, from my understanding of his approach Dr. Sharma still fundamentally believes 'obesity' (however it's defined) to be a problem, and its elimination and / or reduction a desirable objective. Whereas I, funnily enough, don't. As one who considers fat people beautiful, desirable, legitimate and 'normal' expressions of variety within a species whose greatest strength is its diversity and adaptability, and whilst I give him due credit for asking a few more questions than most and resisting participation in the frenzy of morally outraged fatty-bashing that's become de rigeur amongst his profession, I nevertheless can't accept his message.

"What is right is not always popular and what is popular is not always right" - Albert Einstein

I respect Dr. Sharma, because I do think he's an improvement on a lot of other specialists in his field. However, I think Richie makes a lot of good points. He promotes the "obesity=disease" thing, and his recommendations still make assumptions about fat people's habits and don't mandate enough back and forth between the doctor and patient.

Doctors need to do more than ask patients if they want to discuss their weight and label them as "noncompliant" or at least "not ready" if they don't. They need to listen to what patients tell them about their habits, believe what they're told, and tailor their recommendations to that information. His posts are still riddled with the assumption that all fat people overeat and are physically inactive.

There are cases where fat people, especially as they age, will develop health issues that being heavier is a risk factor for. Weight loss by any means necessarily is still not always the best option for those people. It may be better to treat the health issues using the same methods that would be used with someone lighter. It's a complex issue, especially since weight loss attempts most often fail in the long term and may do more harm than good.

You may have forgotten to press the "post" button after viewing the preview. Happens to me all the time. Member's comments on this site aren't moderated. They appear right after they've been posted, and you can check right after posting to make sure it worked.

I think Dr Sharma's biggest error is in thinking that most doctors will come around to his way of thinking about obesity and how to treat fat patients. Until there's a paradigm shift and the way students are taught in med school changes, most doctors are going to see fat patients as lazy over-eaters who are non-compliant when they don't automatically agree to the Nightmare on ELMM Street. Every doctor I've had has this view - calories in/calories out works, and it doesn't matter how few calories you're eating, if you're still gaining weight on that, then you need to increase your exercise. *headdesk*
I just got that from my new doctor and I almost slapped him when he told me that. I told him I refuse to diet anymore, that diets have done nothing but make me fatter, and until he can come up with something better than the Nightmare on ELMM Street, he had better just treat my ailments the same way he'd treat a thinner person or I'd be looking for another doctor, again. He insisted on lab work to check all my vitals, and made me track my blood pressure for a week because it was a little high that day (gee, I wonder why). I got the results of those lab tests and everything was normal (like it has been for the entire 35 years that I've been DEATHFATZ), and I handed in a week's worth of blood pressure readings taken at home (all normal) and haven't heard anything from him since. In fact, he was supposed to call me with the results of my lab tests, and a week later, I had to call him to find out what they were. I think he was pissed that he was wrong about me having diabetes/fatty liver disease/high blood pressure/etc. Just because I'm fat, arthritic, and use a walker because of my mobility issues doesn't mean I'm not metabolically healthy, and more doctors need to realize that about their fat patients.

The problem is, obesity should be treated as a possible medical symptom. Doctors shouldn't jump on obesity as the cause for everything that ails the patient, and shouldn't even assume that any problems a patient has are caused by the obesity. Instead, it should be looked at to create a baseline, and then used in further diagnosis when appropriate.

A good example: sleep apnea. Many assume that sleep apnea is caused by obesity. The truth is, while being fat MAY exacerbate sleep apnea (it depends completely on the person, where the fat is stored and other factors like that), it is most often the other way around. Sleep apnea can be a contributing factor in weight gain. So if a patient has gained weight, that should be one symptom (among many) that is considered to decide if someone needs to be tested for sleep apnea.

Likewise, I would WANT a doctor to look for possible diseases or medical problems that can cause weight gain - hormonal balances being off, glandular issues, things like that.

The problem is, when a patient is considered obese by the doctors, many times those things are either not checked at all, or just skimmed over, and the general answer to the patient is "lose weight". Which for many is not realistic, even more so if they have but are not diagnosed with a condition that can cause weight gain.

I think all of that was my way of saying that I don't think obesity should be classified as a disease, but as a possible symptom to help in diagnosing other problems. Ignoring it completely isn't the answer, but neither is making it the "easy" answer to everything that ails the patient.

most doctors are going to see fat patients as lazy over-eaters who are non-compliant when they don't automatically agree to the Nightmare on ELMM Street

This is a slight departure from the main topic here, but as I was reading your comment, Vesta, a question occurred to me.

Versions of your experience with your doctor are so common with fat people: being lectured, hectored, diagnosed with maladies we don't actually have, enthusiastically threatened with others, and in general being treated like crap. And my question is: does any other group of patients get the same treatment based on "voluntary" conditions?

Smokers? Alcoholics? People known to be using drugs or engaging in promiscuous sex? These are all risky behaviors, from the point of view of one's health. And there are others too. Are runners shamed for the toll their sport takes on their knees and warned that if they keep it up they'll start to lose significant mobility before they're sixty?

And, if other groups of people don't get the same treatment, what makes us so special?

I suspect/hear that they [other groups] do get some degree of this, although I don't have first-hand knowledge of it. And certainly, promiscuity, alcoholism, and increasingly smoking have cultural baggage attached to them. I think that one way fat is different, though, is that fat is associated (both in the sense of "often occurs at the same time as" and "in people's minds") with a LOT of different conditions. Someone who is perceived as "slutty" might get lectured by their doctor and might be told it's karma if they get an STD, but the number of ailments that are likely to be blamed for that are relatively limited. With fat, we are constantly getting headlines that X, Y, and Z might be linked to obesity, included seemingly-unrelated conditions like autism and Alzheimer's.

I suspect smokers and alcoholics get a reasonable share of lecturing. Though perhaps fat people get a more intense level of lecturing. I think its partly because our difference is so very visible and partly because I think there are very strong, deep seated views in many people that fat people are fat because they're lazy, greedy, not trying, taking more than their fair share, not showing self control, etc, etc, etc. I think the majority view is that fat people are only fat because they're lazy and greedy, that we are willfully flouting a moral imperative to obey health precepts. The majority view is that fat people should be told to shape up and stop being lazy and greedy. Plus, we are in the middle of a moral panic that fat people are actively harming the fabric of society, and we are providing an easy scapegoat for a lot of world problems that don't have easy solutions. Doctors are succeptable to all these views. Plus I think they are desperate to carry on believing that "everyone can keep the weight off if they really want to, and if they say they can't, they're just lazy, greedy, and just not trying hard enough". Obviously the solution to this is to lecture us that it's our fault we're fat and we should just try harder. This avoids having to face realising the dieting dogma they've been pushing for decades is an utter failure.

"we are providing an easy scapegoat for a lot of world problems that don't have easy solutions."

This, 100%; cuts to the very heart of it IMHO. After all one of the major drivers of moral panics and scapegoating of 'deviant' groups is the social anxiety associated with periods of rapid social, moral or technological change, and I'd argue that right now we're in the middle of all three, very little of it being positive. And I also share your belief that a lot of the additional hatred which fat people face compared to smokers, drinkers, users of drugs etc (all of whom face some degree of stigma) can be explained by the fact that it is much harder (if not impossible) for us to 'pass' as 'normal' than most of those within the other groups. Which just serves to illustrate the shallow and superficial motivation of much of the hostility to fat. Health, my arse.

"What is right is not always popular and what is popular is not always right" - Albert Einstein